Transcript Chapter 4: Communication and Documentation

Chapter 4
Communications
and Documentation
National EMS Education
Standard Competencies (1 of 5)
Preparatory
Applies fundamental knowledge of the
emergency medical services (EMS) system,
safety/well-being of the emergency medical
technician (EMT), medical/legal and ethical
issues to the provision of emergency care.
National EMS Education
Standard Competencies (2 of 5)
Therapeutic Communication
Principles of communicating with patients in a
manner that achieves a positive relationship
– Interviewing techniques
– Adjusting communication strategies for age,
stage of development, patients with special
needs, and differing cultures
– Verbal defusing strategies
– Family presence issues
National EMS Education
Standard Competencies (3 of 5)
EMS System Communication
Communication needed to
– Call for resources
– Transfer care of the patient
– Interact within the team structure
– EMS communication system
– Communication with other health care
professionals
– Team communication and dynamics
National EMS Education
Standard Competencies (4 of 5)
Documentation
– Recording patient findings
– Principles of medical documentation and report
writing
National EMS Education
Standard Competencies (5 of 5)
Medical Terminology
Uses foundational anatomic and medical
terms and abbreviations in written and oral
communication with colleagues and other
health care professionals
Introduction (1 of 3)
• Communication is the transmission of
information to another person.
– Verbal
– Nonverbal (through body language)
• Verbal communication skills are important
for EMTs.
– Enable you to gather critical information,
coordinate with other responders, and interact
with other health care professionals
Introduction (2 of 3)
• Documentation
– Patient’s permanent medical record
– Demonstrates appropriate care was delivered
– Helps others in patient’s future care
• Complete patient records
– Guarantee proper transfer of responsibility
– Comply with requirements of health
departments and law enforcement agencies
– Fulfill your organization’s administrative needs
Introduction (3 of 3)
• Radio and telephone communications
– Link you to EMS, fire department, and law
enforcement
– You must know:
• What your system can and cannot do
• How to use system efficiently and effectively
Therapeutic Communication
(1 of 4)
• Uses various communication techniques
and strategies:
– Both verbal and nonverbal
– Encourages patients to express how they feel
– Achieves a positive relationship with patient
Therapeutic Communication
(2 of 4)
• Shannon-Weaver communication model
– Sender takes a thought
– Encodes it into a message
– Sends the message to receiver
– Receiver decodes the message
– Sends feedback to the sender
Therapeutic Communication
(3 of 4)
Therapeutic Communication
(4 of 4)
Age, Culture, and Personal
Experience (1 of 2)
• Shape how a person communicates
• Body language and eye contact greatly
affected by culture
– In some cultures, direct eye contact is impolite.
– In other cultures, it is impolite to look away while
speaking.
Age, Culture, and Personal
Experience (2 of 2)
• Tone, pace, and volume of language
– Reflect mood of person and perceived
importance of message
• Ethnocentrism: Considering your own
cultural values more important than those of
others
• Cultural imposition: Forcing your values
onto others
Nonverbal Communication
(1 of 2)
• Body language provides more information
than words alone.
• Facial expressions, body language, and eye
contact are physical cues.
– Help people understand messages being sent
Nonverbal Communication
(2 of 2)
• Physical factors
– Noise: Anything that dampens or obscures true
meaning of message
– Proxemics: Study of space and how distance
between people affects communication
Verbal Communication (1 of 2)
• Asking questions is a fundamental aspect of
prehospital care.
– Open-ended questions require some level of
detail.
• Use whenever possible.
• Example: “What seems to be bothering you?”
Verbal Communication (2 of 2)
– Closed-ended questions can be answered in
very short responses.
• Response is sometimes a single word.
• Use if patients cannot provide long answers.
• Example: “Are you having trouble breathing?”
Communication Tools
• There are many
powerful
communication
tools that EMTs
can use:
– Facilitation
– Silence
– Reflection
– Empathy
– Clarification
– Confrontation
– Interpretation
– Explanation
– Summary
Interviewing Techniques (1 of 4)
• When interviewing a patient, consider using
touch to show caring and compassion.
– Use consciously and sparingly.
– Avoid touching the torso, chest, and face.
Interviewing Techniques (2 of 4)
• Golden Rules to help calm and reassure
patient:
– Make and keep eye contact at all times.
– Provide your name and use patient’s proper
name.
– Tell patient the truth.
Interviewing Techniques (3 of 4)
• Golden Rules (cont’d):
– Use language the patient can understand.
– Be careful what you say about patient to others.
– Be aware of your body language.
– Speak slowly, clearly, and distinctly.
Interviewing Techniques (4 of 4)
• Golden Rules (cont’d):
– For the hearing-impaired patient, face patient so
he or she can read your lips.
– Allow the patient time to answer or respond.
– Act and speak in a calm, confident manner.
Communicating With Older
Patients (1 of 4)
• Identify yourself.
• Be aware of how
you present
yourself.
• Look directly at
patient.
• Speak slowly and
distinctly.
Communicating With Older
Patients (2 of 4)
• Explain what you are going to do before you
do it.
• Listen to the answer the patient gives you.
• Show the patient respect.
• Do not talk about the patient in front of him
or her.
• Be patient!
Communicating With Older
Patients (3 of 4)
• Older patients:
– Often do not feel much pain
– May not be fully aware of important changes in
their body systems
– You must be especially vigilant for objective
changes.
Communicating With Older
Patients (4 of 4)
• When possible, give patients time to pack a
few personal items before leaving for
hospital.
• Locate hearing aids, glasses, and dentures
before departure.
Communicating With Children
(1 of 4)
• Emergency situations are frightening.
– Fear is most obvious and severe in children.
• Children may be frightened by:
– Your uniform
– The ambulance
– A crowd of people gathered around them
Communicating With Children
(2 of 4)
• Let a child keep a favorite toy, doll, security
blanket.
• If possible, have a family member or friend
nearby.
– If practical, let parent or guardian hold child
during evaluation and treatment.
Communicating With Children
(3 of 4)
• Be honest.
– Children easily see through lies or deception.
• Tell the child ahead of time if something will
hurt.
• Respect the child’s modesty.
Communicating With Children
(4 of 4)
• Speak in a
professional,
friendly way.
• Maintain eye
contact.
• Position yourself
at the child’s
level.
– Do not tower
over the child.
Communicating With Hearing
Impaired Patients (1 of 4)
• Most have normal intelligence and are not
embarrassed by their disability.
• Position yourself so patient can see your
lips.
Communicating With Hearing
Impaired Patients (2 of 4)
• Hearing aids
– Be careful they are not lost during accident.
– They may be forgotten if patient is confused.
– Ask family about use of a hearing aid.
Communicating With Hearing
Impaired Patients (3 of 4)
• Steps to take:
– Have paper and pen available.
– If patient can read lips, face patient and speak
slowly and distinctly.
– Never shout.
Communicating With Hearing
Impaired Patients (4 of 4)
Source: © Jones and Bartlett Publishers
. Courtesy of MIEMSS.
• Steps (cont’d):
– Listen carefully, ask short questions, and give
short answers.
– Learn some simple sign language.
• Useful to know signs for “sick,” “hurt,” and
“help”
Communicating With Visually
Impaired Patients (1 of 3)
• Ask the patient if he or she can see at all.
– Visually impaired patients are not necessarily
completely blind.
– Expect your patient to have normal intelligence.
Communicating With Visually
Impaired Patients (2 of 3)
• Explain everything you are doing as you are
doing it.
• Stay in physical contact with patient as you
begin your care.
• If patient can walk to ambulance, place his
or her hand on your arm.
• Transport mobility aids such as cane with
patient to hospital.
Communicating With Visually
Impaired Patients (3 of 3)
• Guide dogs
– Easily identified by
special harnesses
– If possible, transport dog
with patient.
• Alleviates stress for
both patient and dog
– Otherwise, arrange for
care of the dog.
Source: Courtesy of the Guide Dog Foundation for the Blind.
Photographed by Christopher Appoldt.
Communicating With Non
English-Speaking Patients
• You must find a way to obtain a medical
history.
• Find out if patient speaks some English.
• Use short, simple questions.
• Point to parts of the body.
• Have a family member or friend interpret.
Communicating With Other
Health Care Professionals (1 of 3)
• Your reporting responsibilities do not end
when you arrive at the hospital.
• Give oral report to hospital staff member
who has at least your level of training.
Communicating With Other
Health Care Professionals (2 of 3)
• Oral report components:
– Opening information
• Name, chief complaint, illness
– Detailed information
• Not provided during radio report
– Any important history
• Not already provided
Communicating With Other
Health Care Professionals (3 of 3)
• Oral report components (cont’d):
– Patient’s response to treatment given en route
– Vital signs
– Other information
Written Communications and
Documentation (1 of 2)
• Patient care report (PCR)
– Also known as prehospital care report
– Legal document
– Records all care from dispatch to hospital arrival
Written Communications and
Documentation (2 of 2)
• The PCR serves six functions:
– Continuity of care
– Legal documentation
– Education
– Administrative information
– Essential research record
– Evaluation and continuous quality improvement
Patient Care Reports
• Information collected on the PCR includes:
– Chief complaint
– Level of consciousness or mental status
– Vital signs
– Initial assessment
– Patient demographics
Types of Forms (1 of 3)
• Traditional written
form with:
– Check boxes
– Narrative section
• Computerized
version
Source: Courtesy of the Utah Department of Health
Types of Forms (2 of 3)
• The narrative section of the PCR may be
the most important.
• Includes:
– Time of events
– Assessment findings
– Emergency medical care provided
Types of Forms (3 of 3)
• Narrative section (cont’d):
– Changes in patient after treatment
– Observations at the scene
– Final patient disposition
– Refusal of care
– Staff person who continued care
Reporting Errors
• If you leave something out or record it
incorrectly, do not try to cover it up.
• Falsification:
– Results in poor patient care
– May result in suspension and/or legal action
Refusal of Care
• A common source of lawsuits.
– Thorough documentation is crucial.
• Document any assessment findings and
emergency medical care given.
• Have patient sign a refusal form.
– Have family member, police officer, or
bystander also sign as witness.
• Complete the PCR.
Special Reporting Situations
• Depending on local requirements:
– Gunshot wounds
– Dog bites
– Some infectious diseases
– Suspected physical or sexual abuse
– Mass-casualty incident (MCI)
Medical Terminology
• Common terminology among all medical
providers
• Medical personnel around the globe speak
same language: Latin.
• Taking a medical terminology course can be
helpful.
Communications Systems
and Equipment
• Base station radios
• Mobile and portable radios
• Repeater-based systems
• Digital equipment
• Cellular/satellite telephones
• Other equipment
Base Station Radios
• Base station contains transmitter and
receiver in a fixed place.
• Two-way radio consists of transmitter and
receiver.
Mobile and Portable Radios
(1 of 2)
• Mobile radio is
installed in a
vehicle.
• Used to
communicate with:
– Dispatcher
– Medical control
• Ambulances often
have more than
one.
Mobile and Portable Radios
(2 of 2)
• Portable radios are hand-held devices.
• Essential at the scene of an MCI
• Helpful when away from the ambulance to
communicate with:
– Dispatch
– Another unit
– Medical control
Repeater-Based Systems (1 of 2)
• The repeater is a special base station radio.
– Receives messages and signals on one
frequency
– Automatically retransmits them on a second
frequency
– Provides outstanding EMS communications
Repeater-Based Systems (2 of 2)
Digital Equipment
• Voice is not the only EMS communication
• Some EMS systems also transmit:
– Electrocardiograms from unit to hospital
– Paging and tone alerts
Cellular/Satellite Telephones
• EMTs often communicate with receiving
facilities by cellular telephone.
– Simply low-power portable radios
• Satellite phones (satphones) are another
option.
– Can be easily overheard on scanners
Other Communications
Equipment (1 of 2)
• Ambulances usually have an external public
address system.
• Two-way radio hardware may be simplex or
duplex mode.
• MED channels are reserved for EMS use.
Other Communications
Equipment (2 of 2)
• Trunking systems use latest technology to
allow greater traffic.
• Mobile data terminals inside ambulance
– Receive data directly from dispatch center
– Allow for expanded communication capabilities
(eg, maps)
Radio Communications
• The Federal Communications Commission
(FCC) regulates all radio operations in the
United States
– Allocates specific radio frequencies
– Licenses call signs
– Establishes licensing standards and operating
specifications
– Establishes limitations for transmitter output
– Monitors radio operations
Responding to the Scene (1 of 2)
• All EMS systems depend on skill of
dispatcher.
– Determines relative importance of 9-1-1 call
– Assigns appropriate EMS response unit(s)
– Provides key information to responding units,
including nature of emergency and exact
location
Communicating With Medical
Control and Hospitals (1 of 2)
• Plan and organize
your radio
communication.
• Concise, wellorganized patient
report
– Usually follows
standard format
established by
local EMS system
Communicating With Medical
Control and Hospitals (2 of 2)
• Medical control must be readily available:
– On the radio at the hospital or
– On a mobile or portable unit when you call
Source: © Andrei Malov/Dreamstime.com
Maintenance of Radio
Equipment (1 of 2)
• Like other EMS equipment, radio equipment
must be serviced.
• The radio is your lifeline.
– To other public safety agencies (who protect you)
– To medical control
Maintenance of Radio
Equipment (2 of 2)
• At the beginning of your shift, check the
radio equipment.
• Radio equipment may fail during a run.
– Backup plan must then be followed.
– May include standing orders
Summary (1 of 6)
• The Shannon-Weaver model of
communication is a valuable tool in
understanding the variables involved in
human communications.
• There are many verbal and nonverbal
factors and strategies that are necessary for
therapeutic communication.
Summary (2 of 6)
• Excellent communication skills are crucial in
relaying pertinent information to the hospital
before arrival.
• Sick or injured people may not understand
what you are doing or saying. Therefore
body language and attitude are very
important in gaining the trust of the patient
and family.
Summary (3 of 6)
• Take special care with children, geriatric
patients, hearing-impaired patients, visually
impaired patients, and non-Englishspeaking patients.
• EMTs must have excellent person-toperson communication skills.
Summary (4 of 6)
• You must complete a patient care report
before you leave the hospital. This is a vital
part of providing emergency medical care
and ensuring continuity of patient care.
• Radio and telephone communication links
you to other members of the EMS, fire, and
law enforcement communities.
Summary (5 of 6)
• An EMT must understand and be able to
use many forms of communication,
including mobile and hand-held radios.
• It is your job to know what your
communication system can and cannot
handle. You must be able to communicate
effectively by sending precise, accurate
reports on scene, patient’s condition, and
treatment provided.
Summary (6 of 6)
• Remember, the lines of communication are
not always exclusive; therefore, you should
speak in a professional manner at all times.
• Reporting and record-keeping duties never
come before care of a patient.
Review
1. When health care providers force their
cultural values onto their patients because
they believe their values are better, they
are displaying __________.
A. ethnocentrism
B. proxemics
C. nonverbal communication
D. cultural imposition
Review
Answer: D
Rationale: Forcing your own cultural values
onto others because you believe your values
are better is referred to as cultural imposition.
Review (1 of 2)
1. When health care providers force their cultural
values onto their patients because they believe
their values are better, they are displaying
__________.
A. ethnocentrism
Rationale: Ethnocentrism means considering your
own cultural values as more important.
B. proxemics
Rationale: This is the study of space and how the
distance between people affects communication.
Review (2 of 2)
1. When health care providers force their cultural
values onto their patients because they believe
their values are better, they are displaying
__________.
C. nonverbal communication
Rationale: This term simply means any
communication that does not use language.
D. cultural imposition
Rationale: Correct answer
Review
2. When communicating with an elderly
patient, you should:
A. approach the patient slowly and calmly.
B. step back to avoid making the patient
uncomfortable.
C. raise your voice to ensure that the patient can
hear you.
D. obtain the majority of your information from
family members.
Review
Answer: A
Rationale: Approach an elderly patient slowly
and calmly, use him or her as your primary
source of information whenever possible, and
allow ample time for the patient to respond to
your questions. Not all elderly patients are
hearing impaired; if the patient is hearing
impaired, you may need to elevate your voice
slightly.
Review (1 of 2)
2. When communicating with an elderly patient, you
should:
A. approach the patient slowly and calmly.
Rationale: Correct answer
B. step back to avoid making the patient
uncomfortable.
Rationale: You may need to get closer. You have
to touch the patient to take vital signs.
Review (2 of 2)
2. When communicating with an elderly patient, you
should:
C. raise your voice to ensure that the patient can
hear you.
Rationale: Not all elderly patients are hearing
impaired.
D. obtain the majority of your information from family
members.
Rationale: Always speak to the patient; the
patient’s responses can provide unlimited
information.
Review
3. While caring for a 5-year-old boy with
respiratory distress, you should:
A. avoid direct eye contact with the child, as this
may frighten him.
B. avoid letting the child hold any toys, as this
may hinder your care.
C. realize that it is usually easy to deceive a child
when treating them.
D. allow a parent or caregiver to hold the child if
the situation allows.
Review
Answer: D
Rationale: When caring for children, take special
care to avoid upsetting them. Allowing a parent to
hold the child or allowing the child to play with a
favorite toy often helps to keep the child calm.
Never lie to a child, or any other patient for that
matter; children can see through lies and
deceptions. Assure the child that you can be
trusted and are there to help by maintaining eye
contact.
Review (1 of 2)
3. While caring for a 5-year-old boy with respiratory
distress, you should:
A. avoid direct eye contact with the child, as this may
frighten him.
Rationale: Eye contact helps to establish trust
with children.
B. avoid letting the child hold any toys, as this may
hinder your care.
Rationale: Playing with a toy can calm a child and
keep the child occupied.
Review (2 of 2)
3. While caring for a 5-year-old boy with respiratory
distress, you should:
C. realize that it is usually easy to deceive a child
when treating them.
Rationale: Never lie to a child; children can detect
deception.
D. allow a parent or caregiver to hold the child if the
situation allows.
Rationale: Correct answer
Review
4. Which of the following pieces of patient
information is of LEAST pertinence when
giving a verbal report to a nurse or
physician at the hospital?
A. The patient’s name and age
B. The patient’s family medical history
C. Vital signs that may have changed
D. Medications that the patient is taking
Review
Answer: B
Rationale: Information given to the receiving
nurse or physician should include the patient’s
name and age, vital signs (especially if they
have changed), a summary of the past
medical history, and the patient’s response to
any treatment that you rendered. Family
medical history is not essential in the
emergency treatment of a patient.
Review
4. Which of the following pieces of patient information is of LEAST pertinence when giving a
verbal report to a nurse or physician at the
hospital?
A. The patient’s name and age
Rationale: This is very important in a verbal report.
B. The patient’s family medical history
Rationale: Correct answer
C. Vital signs that may have changed
Rationale: This is very important in a verbal report.
D. Medications that the patient is taking
Rationale: This is very important in a verbal report.
Review
5. Which of the following statements about
the patient care report (PCR) is true?
A. It is not a legal document in the eyes of the
law.
B. It cannot be used for patient billing
information.
C. It helps ensure efficient continuity of patient
care.
D. It is for use only by the prehospital care
provider.
Review
Answer: C
Rationale: The PCR is an important
document for more than one reason. It helps
to ensure efficient continuity of patient care by
providing the hospital with an account of all
prehospital assessments and treatment. It
also serves as a legal document that reflects
the care provided by the EMT.
Review (1 of 2)
5. Which of the following statements about the
patient care report is true?
A. It is not a legal document in the eyes of the law.
Rationale: A patient care report is a legal
document.
B. It cannot be used for patient billing information.
Rationale: A patient care report can be used by
hospital administration, which includes the billing
department.
Review (2 of 2)
5. Which of the following statements about the
patient care report is true?
C. It helps ensure efficient continuity of patient care.
Rationale: Correct answer
D. It is for use only by the prehospital care provider.
Rationale: While it may not be read immediately
by the hospital, it can be used later to review
patient care procedures and for quality
improvement purposes.
Review
6. A device that receives a low frequency and
then transmits it at a relatively higher
frequency is called a:
A. duplex.
B. scanner.
C. repeater.
D. receiver.
Review
Answer: C
Rationale: A repeater receives messages
and frequencies from one frequency and then
automatically transmits them on a second,
higher frequency.
Review (1 of 2)
6. A device that receives a low frequency and then
transmits it at a relatively higher frequency is
called a:
A. duplex.
Rationale: Duplex is the ability to transmit and
receive messages simultaneously.
B. scanner.
Rationale: This is a device that searches or scans
across several frequencies until a message is
completed.
Review (2 of 2)
6. A device that receives a low frequency and then
transmits it at a relatively higher frequency is
called a:
C. repeater.
Rationale: Correct answer
D. receiver.
Rationale: This is a device that only receives and
does not transmit.
Review
7. The success of communications depends
on the:
A. location of the hospital.
B. strength of your voice.
C. efficiency of the equipment.
D. strength of the microphone.
Review
Answer: C
Rationale: A number of factors affect
communication effectiveness; however, the
efficiency of the equipment you are using
ultimately affects the success of
communications.
Review
7. The success of communications depends on the:
A. location of the hospital.
Rationale: The hospital location has no influence
on how successful communication is.
B. strength of your voice.
Rationale: This is important, but it has no impact
on a successful communication.
C. efficiency of the equipment.
Rationale: Correct answer
D. strength of the microphone.
Rationale: The microphone is only one piece of
equipment needed for successful communication.
Review
8. All of the following are functions of the
emergency medical dispatcher, EXCEPT:
A. alerting the appropriate EMS response unit.
B. screening a call and assigning it a priority.
C. providing emergency medical instructions to
the caller.
D. providing medical direction to the EMT in the
field.
Review
Answer: D
Rationale: Functions of the emergency
medical dispatcher include screening a call
and assigning it a priority, alerting the
appropriate EMS response unit, coordinating
EMS units with other public safety services,
and providing prearrival emergency medical
instructions to the caller.
Review (1 of 2)
8. All of the following are functions of the emergency
medical dispatcher, EXCEPT:
A. alerting the appropriate EMS response unit.
Rationale: The dispatcher notifies the closest
appropriate EMS unit.
B. screening a call and assigning it a priority.
Rationale: The dispatcher prioritizes incoming
calls.
Review (2 of 2)
8. All of the following are functions of the emergency
medical dispatcher, EXCEPT:
C. providing emergency medical instructions to the
caller.
Rationale: The dispatcher helps callers with
medical instructions.
D. providing medical direction to the EMT in the field.
Rationale: Correct answer
Review
9. After receiving an order from medical
control over the radio, the EMT should:
A. carry out the order immediately.
B. disregard the order if it is not understood.
C. obtain the necessary consent from the patient.
D. repeat the order to the physician word for
word.
Review
Answer: D
Rationale: After receiving an order from
medical control, the EMT should repeat the
order back to the physician word for word.
This will ensure that he or she heard the order
correctly. After confirming the order, the EMT
should obtain the necessary consent from the
patient.
Review
9. After receiving an order from medical control over
the radio, the EMT should:
A. carry out the order immediately.
Rationale: The order must be repeated back first to
confirm that it was heard correctly.
B. disregard the order if it is not understood.
Rationale: Repeating the order will help the EMT to
clarify any misunderstandings.
C. obtain the necessary consent from the patient.
Rationale: This step is carried out after the order has
been confirmed and understood by the EMT.
D. repeat the order to the physician word for word.
Rationale: Correct answer
Review
10. When requesting medical direction for a
patient who was involved in a major car
accident, the EMT should avoid:
A. using radio codes to describe the situation.
B. questioning an order that seems
inappropriate.
C. relaying vital signs unless they are abnormal.
D. the use of medical terminology when
speaking.
Review
Answer: A
Rationale: When giving a report to medical
control or requesting medical direction, the
EMT should avoid the use of codes, such as
“10-50” or “Signal 70.” One cannot assume
that the physician is familiar with these codes.
Plain English is more effective.
Review (1 of 2)
10. When requesting medical direction for a patient
who was involved in a major car accident, the
EMT should avoid:
A. using radio codes to describe the situation.
Rationale: Correct answer
B. questioning an order that seems inappropriate.
Rationale: If an order seems inappropriate, EMS
providers must question the validity of the order.
Review (2 of 2)
10. When requesting medical direction for a patient
who was involved in a major car accident, the
EMT should avoid:
C. relaying vital signs unless they are abnormal.
Rationale: Vital signs are necessary to describe
the patient’s condition to the medical director.
D. the use of medical terminology when speaking.
Rationale: The use of appropriate medical
terminology shows the EMS provider’s
confidence, knowledge, and expertise to the
medical director.
Credits
• Slide Background Image (ambulance): ©
Galina Barskaya/ShutterStock, Inc.
• Slide Background Images (non-ambulance):
© Jones & Bartlett Learning. Courtesy of
MIEMSS.